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News Initiative Update

New Evaluation: The Fundamental Role of Care Coordination

New Evaluation: The Fundamental Role of Care Coordination

The Meadowlark Initiative brings together a clinical team (made up of prenatal care and behavioral health providers) and coordinates outreach and community services to provide better care for pregnant women and their families, improve health outcomes, and reduce family separation.

This innovative model helps prenatal care providers better address depression, anxiety, substance use, and other issues that contribute to poor pregnancy outcomes. Meadowlark is transforming the way Montana women receive pregnancy and postpartum care.

A recent evaluation of The Meadowlark Initiative found that care coordination plays a central role in improving outcomes – from engaging at-risk patients in care to helping reduce the need for family separation.

The evaluation also found that care coordination plays a critical role in the Meadowlark model by building relationships with patients and connecting them to community resources. Care coordination can also contribute to the overall financial sustainability of the site by reducing no-shows for prenatal appointments.

These are some key findings from the evaluation.

Providing More Adequate Prenatal Care

Care coordinators build relationships with patients and engage them as needed throughout the pregnancy. The heart of this role is establishing mutual trust and supporting people who may be reluctant to seek care because of the stigma associated with mental illness or substance use. Often, care coordination also involves addressing barriers such as transportation, childcare, and domestic violence.

The average percentage of women receiving adequate prenatal care increased from 68% to 85% in all Meadowlark sites, exceeding the state’s average of 77%.

When a patient doesn’t show up for a prenatal appointment, I call to see if she needs help. I think this is why we have more return patients. I know that when a patient doesn’t make it to an appointment, it’s usually because something is going on in her life – not because she doesn’t care about her baby.

Meadowlark Care Coordinator

Providing More Depression & Substance Use Disorder Screening

Having a behavioral health provider and a care coordinator embedded in the clinic or medical system gives providers the confidence to initiate conversations about behavioral health and social determinants, knowing that there are specific and appropriate resources they can offer patients in need of support.

The percentage of sites universally screening their patients for depression increased from 10% to 70% in Meadowlark sites, and the percentage of sites screening for substance use disorders increased from 40% to 90%.

I have seen a more rounded and comprehensive approach to our patients and an increased sensitivity to all aspects of care. As providers, we ask more questions now that we have ways to help patients!

Meadowlark Obstetrics Provider

Reducing the Risk of Premature Births

Substance use disorders, mental illness, and socioeconomic factors like poverty and poor nutrition increase the risk of premature births. Care coordinators’ practical support is pivotal in supporting patients’ mental health and physical well-being during pregnancy.

Across Meadowlark sites, the percentage of premature births was 8.8% during the grant period, lower than the state’s average of 9.8% and the national average of 10.5% and lower than available baseline data for these sites.

Supporting Fewer Family Separations

For patients with a substance use disorder, care coordinators serve as advocate for the patient by helping the prenatal care team establish a relationship with the local and regional Child and Family Services Division (CFSD). Meadowlark providers work with families affected by substance use to create a “Plan of Safe Care.” Through this collaboration, CFSD staff can better understand each situation and respond to drug-exposed births with a greater awareness of the patient’s history and the steps they are taking toward recovery – reducing the need for family separations.

The average percentage of infant removals decreased from 2.6% to 1.4% in all Meadowlark sites. CFSD data also shows a lower proportion of removals in counties with a Meadowlark site versus the state overall.

Care coordination is central to the success of the Meadowlark model of care, yet the reimbursement for prenatal care often does not fully offset the costs of this position. Some practices have found that the reduction in no-show rates that care coordinators help create can offset the costs of the position. To ensure that all Meadowlark practices across the state can sustain this model in the long term, Montana Medicaid and private payers may need to consider enhanced reimbursement for implementing the Meadowlark model of care.

Read the full evaluation here. 

The Meadowlark Initiative is funded and supported through a partnership between the Montana Healthcare Foundation and the Montana Department of Public Health and Human Services.